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Saturday, February 21, 2009

Just The Tip of the Iceberg

The TIME article ("The Trouble With Repeat Cesareans") has a number of good points in it, particularly on the issues of "choice," but in many ways it only begins to touch on how much VBAC is discouraged in this country nowadays.

One of the things that most irritates me is doctors trying to promote the idea that women "don't wan't" VBAC anymore. That's total nonsense. Many MANY women still want VBACs but their hospitals or doctors won't "let" them. Others are scared out of VBACs by distorted scare tactics from doctors who just don't want to do VBACs.

"The decline in VBACs is driven both by patient preference and by provider preference," says Dr. Hyagriv Simhan, medical director of the maternal-fetal-medicine department of Magee-Womens Hospital of the University of Pittsburgh Medical Center.

But while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them. Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won't allow the procedure, is concerned that women are getting "skewed" information about the risks of a VBAC "that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision."

According to a nationwide survey by Childbirth Connection, a 91-year-old maternal care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

ICAN's 2009 survey of U.S. Maternity hospitals found that 28% had an outright ban on VBAC, and another 21% had a "de-facto" ban.....meaning that the hospital had no policy against VBAC but no doctors there would attend one. As noted before, this means that about half of all U.S. hospitals basically do not let women choose VBAC.

But this is only the tip of the iceberg. Even in the hospitals where VBAC is ostensibly "allowed," they are often rare. Doctors either scare women out of them or suddenly find reasons why they "must" schedule a repeat cesarean as they get closer to term.

Doctors scare women out of VBACs by giving them "informed consent" forms that list huge and graphically-detailed risks for VBACs (even though these risks are statistically rare), and a few minor and skimmed-over risks for repeat cesareans (even those these risks are statistically about as common). They are told horror stories by doctors of rare complications, yet not told similar horror stories of similarly common complications with repeat cesareans.

In short, they are not being given fair and balanced informed consent about the benefits and risks of VBACs and repeat cesareans. Are these women really getting true "choice" in deciding about VBACs? Are these women really having truly "elective" cesareans? Hardly.

Other women are told they can "try" for a VBAC but as they get closer and closer to the end of pregnancy, suddenly the doctor comes up with all kinds of rules that they have to meet....the baby has to be under xxx pounds, she has to go into labor before her due date, she has to be well-dilated and the baby "engaged" in her pelvis by 38 weeks, yadda yadda.

Author Henci Goer calls this the "Cinderella VBAC" scenario. (Sure you can go to the ball, dear....you just have to meet this impossible list of tasks and conditions first. And even if you somehow do, we'll still probably pull the rug out from under you at the last minute.)

So even in those hospitals where a doctor "allows" VBACs, many of those women get talked out (or risked out) of them at the last minute. This is yet another tactic in the war on VBACs in this country.....make it look like you support VBAC but pull the old "bait and switch" at the end.

Statistics show that around 70% of women who try for a VBAC end up having one.....but most women are not given a chance to be in that 70%. Either they are outright banned from having the choice, are discouraged out of it with distorted scare tactics, or are subjected to "bait and switch" schemes where they are conveniently pressured into a cesarean at the last moment.

Only about 8% of women with previous cesareans go on to have a VBAC in this country nowadays, down from 28% in 1996.....purely because almost NONE of them are given the choice.....or a realistic chance......to try.

That's how far the VBAC-lash pendulum has swung now.....and the figures for women of size nowadays are even more abysmal.

In the end, this will have major consequences for the long-term health of mothers and babies in this country, as the cesarean rate spirals out of control. As the article noted:

Patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs....With each repeat cesarean, a mother's risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman's chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta--in which the placenta attaches abnormally to the uterine wall--has increased thirtyfold in the past 30 years. "The problem is only beginning to mushroom," says ACOG's Zelop.

The story is not just that half of all US hospitals do not let women choose VBAC, although that in itself is a pretty darn big story.

The even BIGGER story is that even in those hospitals that "permit" VBAC, very few women are actually getting a realistic chance at one.

The story on women's choices in childbirth is even grimmer than is being presented.

6 comments:

I've been reading your blog for a while, but I think I just realized that you used to run the Plus-Size Pregnancy website? Are you kmom?

If so, I want to give you a huge, hearty thanks for your website. I think I e-mailed you several years back, about how much your website helped me when I was pregnant. I had some high blood pressure readings that caused all sorts of concern, and after reading your site I realized it was likely because the weight I'd gained in the pregnancy was enough to make me need a larger blood pressure cuff. After that my blood pressure readings came down, and I felt empowered to request the larger cuff, even when nurses who I think were trying to be nice would tell me "Oh, you don't need it; you're not that big." I had measured my arm, and I knew what cuff I needed, thanks to your site.

Your blog is great. Keep up the good work! I'm actually headed to the doctor tomorrow to get my IUD removed and start trying for #2, and I'm so happy to see that you're still out there advocating for larger pregnant women.

Yup, I'm kmom, and I still run my website, www.plus-size-pregnancy.org. The blog takes up more of my time these days but I still work on the website too.

I'm glad to hear my website was helpful to you!! Always great to hear feedback like that. I'll have to do a blog entry on BP cuffs one of these days, then link to my website FAQ on the topic. Thanks for the reminder!

An entry on BP cuffs would be great. I've known a few other plus-size moms who've had similar issues with the BP cuffs.

This is sort of an aside, but I'm thinking of it again because we're about to start trying again. What are the recommendations for cuff size when your arm circumference is on the border? My arm is 12-1/2" around, and I have some doctors who will use a smaller cuff, and some who use a larger cuff. Right now it doesn't matter either way, but obviously it will be more of an issue in a pregnancy.

Is it generally safer to err on the side of a larger cuff or a smaller cuff?

An excellent question, Lori. I don't have a great answer for you, alas.

Studies show that around 13 inches is where a larger cuff needs to be used. However, studies also show that error starts to show up earlier than that, just not really as significant an error. Elevated pressures start to happen around 11.5 to 12 inches, iirc.

So you are really right there on the border. You could use either. Which you SHOULD do, I really couldn't say. It's a difficult call.

The risk of using the smaller cuff is that you might get an elevated pressure that's not really accurate, and get unnecessary treatment with all the risks of that. That can be significant.

The risk of using a too-large cuff is that it can underestimate BPs, and so they might miss a problem starting to happen. That might also be worrisome.

So really, when you are in that borderline area, you are in no-man's-land. It's really not clear if you should use the smaller or larger cuff in that situation.

I'm also on the border of 2 cuff sizes, the large and the thigh cuff. Generally I'm okay with a large cuff and don't need a thigh cuff but if my BP comes out borderline or high, I check the cuff size and if I'm really close to the top cutoff, I ask for the thigh cuff. If I'm not really close to the top cutoff, I stick with the large cuff. Now, my BP has mostly been normal so that's why I err on the side of the larger cuff if in doubt, but if I tended towards significantly high BP I might err on the other side, you know?

I don't really know if that's the best course or not, but it seemed a reasonable compromise to me.

Sorry I don't have a definitive answer for you; it's a question I've long wondered about myself.

So grateful to you for your sites! Lots of hard work. I actually gained weight on purpose, I truly like my body and consider my size "normal". I find flesh more attractive than skin and bones by far! While "obese" I wouldn't consider myself "fat" exactly because my flesh is muscled. But my weight is high enough that walking becomes difficult if I lose fitness. The extra weight I gained over the past 9 months has me calling myself "fat", but that changes quickly with a little exercise. My perceptions so diverge from the skinny conformists that it makes me laugh (with gusto.) Although slim can be ok too. Another thing. I'm very interested in data on hormonal differences in bigger and middle-aged women that make pregnancy tests inaccurate. (I'm nowhere near Methusala's age BTW.) My beliefs are that starting my family now is better and moving towards, well, back towards Eden. Just wondering what might make tests (incl ultrasound) not work in some women. I think it's so cool that I have a better chance of having twins naturally now too - aren't we a marvelous work!

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